Improvement Plan In-Service Presentation

CAPELLA UNIVERSITY

SCHOOL OF NURSING AND HEALTH SCIENCES

Mar 2021

Content

• Importance of safe medication administration
• Purpose and goals of the in-service session
• Need for safety outcome
• Process of safety outcome
• Role and importance of the audience
• Resources to improve medication administration
• Activities for to skill development and QI plan

This is the content of the presentation. It begins with the importance of safe medication administration. We will look at the project objectives along with purpose and goals of the in-service session to understand what goals needs to achieved. Further, we will see how a team or role of the audience, which is you plays a critical role in this project. Then comes strategies, resources, and activities that will promote the Interprofessional group collaboration, skill development, and understanding process involved in safe medication administration. Further, resources and activities to encourage skill development and process understanding related to a safety improve initiative on medication administration. 

Importance of safe medication administration

• Medication administration errors reduce quality care
• Increases threat to patient safety
• Increases burden on nurses
• Increased hospital stay 
• Frequent hospital readmission
• Adverse effects and sentinel events

• Medication administration is a critical process where nurses play a key role. However, stakeholders such as physicians, pharmacists, informatics nurses, and other health care professionals contribute to it as the process includes medication prescription, dosage calculation, medication dispensing, and error monitoring. Error in any of the stages will lead to medication administration errors. 
• There are different types of medication errors, which include dosage errors, wrong or improper package information, drug-drug interactions, mismatch in patient’s electronic health records, and poor medication administration (Schmidt et al., 2017). Some of the errors can have an adverse effect on patients and even lead to morbidity and mortality. In their study, Kang et al. (2017) reported that at least five near misses every month, 14.8% of dispensing errors, 4.3% administration errors, and 43.9% prescription errors were from 32 pharmacies. However, only 37.1% prescription errors, 57.4% administration errors, and 43.7% dispensing errors were reported. Salar et al. (2020) highlighted that prevalence of errors varies from 32.1% to 94%. Also, 23%, 38%, and 39% of medication errors were associated with pharmacies, nurses, and general practitioners respectively (Salar et al., 2020).
• Medication errors increase cost, the burden on dispensing, administration, and packaging units. Cumulatively, it leads to work burden on the nurses and reduces patient satisfaction level and trust in health care (Musharyanti et al., 2019). 
• Risk factors include mortality, morbidity, and adverse effects. Every year, 7000 to 9000 patients in the US die due to medication errors (Tariq et al., 2021). The errors lead to increased hospital stay cost o $40 billion per year with more than 7 million patients affected by the issue (Thomas et al., 2017). As a result, it is important. 

NURS FPX 4020 Assessment 3: Improvement Plan In-Service Presentation

Purpose of the in-service session

The purpose of the in-service session is to educate and prepare the nursing and health care professionals to understand the importance of an QI plan to increase medication administration safety by exploring process of safety outcome, role of health care professionals, resources needed to implement QI plan, and conduct activities to understand the process. 

Objectives and goals

• To highlight need for safety QI plan for medication administration

• To improve knowledge and competency

• To improve communication skills among nursing personnel

• To increase interprofessional collaboration

• Understand strategies to implement QI plan

Objectives and goals

• Understand importance of interprofessional collaboration

• To update knowledge regarding different strategies

• To update knowledge regarding EHRs, bar-code systems, error reporting mechanism, and hospital protocols

• To provide resources and activities related to medication administration

Need for safety outcome

• Nurses and other health care professional are committing medication errors

• Lack of knowledge regarding strategies for interprofessional collaboration 

• Mediation errors increases burden on patients, nurses, and health care

• Every organization aims and individual aim to provide high quality and safer care

• Interprofessional education helps to improve interprofessional collaboration and patient care through the promotion of various professions of health to increase interprofessional collaboration compared to single profession education, which individuals learn in isolation and merely in their profession. Therefore, interprofessional education of medication safety program can reduce medication error and promote patient safety in the ICUs.

• Burnout is common among nurses. As a result, communication and a supportive work environment are critical. Nurses can coordinate with each other during medication administration to handle any interruptions.

• Medication errors and ADEs are an underreported burden that adversely affects patients, providers, and the economy.

NURS FPX 4020 Assessment 3: Improvement Plan In-Service Presentation

Process of safety outcome

• The first EBP solution is to train and educate nurses to follow guidelines

• Implement a physician order entry system

• Bar-code based medication scanning

• Implement an automated error reporting system 

• Checklists to double check the medication

• The first EBP solution is to train and educate nurses and health care staff to follow the guidelines provided by IOM and QSEN. The guidelines include being vigilant and verify medication with EHRs, check for allergies, assess the medication before administration, diligently calculate dosage (Armstrong, 2019), use memory aids and checklists, avoid workarounds, avoid conversations during administration, consider one patient at a time, clarify an unclear prescription, and avoid abbreviations (Pop & Finocchi, 2016). The process reduces cost as it prevents adverse effects of medication on patients. 
• The second EBP is to implement a physician order entry system with medication error reporting and communication system to reduce prescription, dispensing, and administration errors (Thompson et al., 2018). The system is completely electronic where nurses, physicians, and pharmacists are directly connected to compare medication with prescription and EHR to detect any discrepancies. 
• Further, implementing technology such as bar-code-based medication administration where each drug has a unique barcode helps in preventing dispensing errors and dosage errors (Thompson et al., 2018). 

• The next strategy is to implement an automated error reporting system that includes a patient-specific automated medication system (npsAMS) unit, barcode medication administration (BCMA), and a complex automated medication system (cAMS) with the automated dispensing unit to reduce human errors in communication and decision-making. As the process used an integrated system, the errors were reduced from 0.96 to 0.15 (Risør et al., 2018). 

• Koyama et al. (2021) proposed an EBP strategy to double-check medicine through the checklist, implementing hierarchical protocols, and educating interprofessional teams to reduce medication administration errors. The strategy reduced errors as double-checking reduced human errors. Also, recommendations by QSEN and IOM to train health care staff to communicate and collaborate aid in both error prevention and management (Abukhader & Abukhader, 2020).

NURS FPX 4020 Assessment 3: Improvement Plan In-Service Presentation

Process of safety outcome

• Encourage interprofessional collaboration

• Use of tabards to prevent interruptions

• Implement RCT process to eliminate blame culture

• Create a role-based work culture

• Reduce nurse burnout by increasing nurse-patient ratio

• The imprtant step is to develop a hospital-based protocol and hierarchical response system with a medication error alert system to quickly detect the errors and provide steps taken to report the error along with the responsibilities of different stakeholders (Huckels-Baumgart et al., 2017). This plan aid in solving the first root-cause where the pharmacist sent the wrong product. The outcome of this step is it increases knowledge and competencies along with better communication between the team (Korb-Savoldelli et al., 2018). 

• Burnout is common among nurses. As a result, communication and a supportive work environment are critical. Nurses can coordinate with each other during medication administration to handle any interruptions (Hammoudi et al., 2017). For example, a nurse can attend a patient of another nurse or external patient for the time being till the assigned nurse completes his or her administration to reduce mix-ups and confusion. Also, communicating with other nurses to identify allergies in a patient to create a patient-specific medication order prevents adverse effects (Huckels-Baumgart et al., 2017). 

Composition of safety team

• Decision-making
  • Nurse leaders
  • Nurse managers
  • Chief of unit (pharma, residents, surgeons, and others

• Team members
  • Nurses 
  • Physicians
  • Pharmacist
  • Informatics nurse
  • IT professionals

• Decision-making team includes nurse leaders, managers, and unit chiefs as they draft the policies and take decisions whenever there is an issue. Also, they monitor the resources and finances involved in the units. However, other members such as nurses and physicians provide their input in medication administration activities. 
• Medication administration includes nurses as they administer drugs, match the drug by comparing with EHRs, and report any errors. It also includes physicians as they prescribe drugs and dosage. Pharmacist dispenses the medication by checking the order against prescription. Informatics nurses handles EHRs and other tools. IT professional help in troubleshooting any issues in system and devices. 

NURS FPX 4020 Assessment 3: Improvement Plan In-Service Presentation

Interprofessional collaboration strategies

• Team building activities
• Encourage open communication
• Enable knowledge-sharing
• Integrate shared decision-making
• Reward and recognize
• Setting common goals and platform to discuss

• Team building activities are one of the great ways to bring the employees closer as it allows the team members to understand each other’s perspectives, ideas, and thoughts (Zhang & Cui, 2018).
• Encourage open communication: open communication allows everyone to express their views effectively. this increases in-flow of information and critical analysis (Truglio-Londrigan & Slyer, 2018)
• Enable knowledge-sharing: the group members can share their knowledge to others to highlight certain points and also it helps in gaining knowledge as others have something to share too
• Reward and recognize: incentive-based approach or reward and recognize motivates the workers to work towards common goal to achieve desired productivity (Zhang & Cui, 2018). 
• Integrate shared decision-making: this reduces autocratic leadership and promotes democratic leadership as input from everyone is important. It is crucial in increasing diversity. 
• Setting common goals and platform to discuss – this drives all the focus towards set of goals instead of individual goals (Truglio-Londrigan & Slyer, 2018)

NURS FPX 4020 Assessment 3: Improvement Plan In-Service Presentation

Role of the audience

• Research and understand the issues
• Understand strategies, policies, and guidelines
• Educate peers through collaboration
• Work towards achieving safety goals 
• Communicate and coordinate with hospital staff
• Report and address adverse and sentinel events

Importance of the audience

• Nurses are important as they administer medicines

• Physicians prescribe the orders

• Pharmacist dispenses the order

• Informatics nurses maintain EHRs 

• Technician troubleshoot issues in EHRs 

NURS FPX 4020 Assessment 3: Improvement Plan In-Service Presentation

Resources to improve medication administration

• Improving Medication Safety by ACOG

• Guidelines by QSEN and IOM

• Literature and protocol manuals provided by health care

• EBP research articles and strategies

QSEN Competencies useful for practice improvement of Vaccine Safety, Medication Errors, Polypharmacy, Communication Breakdowns, Test Result Follow up, HER Errors & Diagnostic Errors

1. Patient Centered Care
   1. Knowledge
      1. Discuss principles of effective communication
      2. Describe principles of consensus building and conflict resolution

• Examine how the safety, quality & cost effectiveness of health care can be improved through involvement of patients/families

1. Equity issues-culture-language
2. Skills:
   2. Communicate care provided & needed at each transition in care
3. Attitude
   2. Value the patient’s expertise with own health and symptoms
   3. Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care
4. Teamwork & Collaboration
   2. Knowledge
      2. Describe strategies for ID & managing overlaps in team member roles & accountabilities
      3. Analyze differences in communication style preferences & impact on others

• Discuss effective strategies for communicating & resolving conflict

1. ID system barriers for effective team function
2. Skills
   3. Participate in designing system that support team work
   4. Follow communication practices that minimize risks associate with handoffs among providers & across transitions in care
3. Attitudes
   3. Appreciate risk associated with handoff & transitions in care
4. Evidence Based Practice
   3. Knowledge
      3. Explain the role of evidence in determining best clinical practice
      4. Describe reliable sources for locating evidence reports & clinical practice guidelines
   4. Skills
      3. Locate evidence reports related to clinical practice topics & guidelines
      4. Question rational for routine approaches to care that result in less-than desired outcomes or adverse events
   5. Attitudes
      3. Value the need for continuous improvement
      4. Appreciate the risks associated with handoffs among providers and across transitions in care

4. Safety:
   4. Knowledge
      4. Examine human factors & basic safety design, common unsafe practices
      5. Evaluated safety enhancing technology (barcodes, CPOE)

• Describe how root cause analysis can help us understand when safety event or error occurs

1. Skills
   1. Use of technology & standardized practices that support safety & quality
   2. Strategies to reduce reliance on memory

• Participate in appropriately analyzing errors & design system improvements

1. Engage in RCA when error/near miss occurs
2. Attitudes
   2. Appreciate the cognitive and physical limits of human performance
   3. Value own role in preventing errors
3. Informatics
   2. Knowledge
      1. Describe examples of how technology & information management are related to quality & safety
   3. Skills
      1. Apply technology & information management tools to support safe processes of care
   4. Attitudes
      1. Appreciate the necessity for all health professionals to seek lifelong, continuous learning of information technology skills
      2. Value technologies that support clinical decision-making, error prevention, and care coordination

• Value nurses’ involvement in design, selection, implementation, and evaluation of information technologies to support patient care

6. Quality Improvement
   6. Knowledge
      6. Importance of variation & measurement in assessing quality of care
      7. Described approaches for changing processes of care
   7. Skills
      6. Use quality measures to understand performance
      7. Identify gaps between local & best practice

• P-D-S-A to test change in daily work

1. Use tools helpful for understanding variation
2. Attitude
   1. Appreciate that continuous quality improvement is an essential part of the daily work of all health professionals
   2. Appreciate the value of what individuals and teams can to do to improve care

Activities for to skill development and QI plan

• Analyzing a medication error case study

• Discussing root-causes in the case study

• Discussing challenges faced by health care professionals

• Analyzing what could have averted the error

• Implementing EBP changes in the future

The patient has been admitted to a 20-bed medical unit for treatment of acute diverticulitis. The provider has ordered Ultram (Tramadol hydrochloride) 50 mg p.o. every 6 hours prn pain. The patient is requesting a pain medication, as it has been 8 hours since his last dose. The nurse selects the individually wrapped medication from the patient’s assigned medication drawer and scans the barcode to determine if it is the correct medication. The scanner is not working again. As she wants to administer the pain medication as soon as possible, she types in the Internal Entry Number (IEN) and the computer indicates the medication is Ultracet 37.5/325 mg but the package says Ultram 50 mg. The nurse calls the pharmacy and the pharmacist says there is only one number different between Ultram and Ultracet and, since the package says Ultram, to administer the medication because she must have typed in the wrong number. The nurse administers the medication, and within 30 minutes the patient shows signs of an allergic reaction. The nurse checks the record and determines the patient is allergic to acetaminophen. The patient is treated for the allergic reaction, and a medication incident form is completed. The nurse manager asks for a Root Cause Analysis (RCA) to be completed for the medication error.

NURS FPX 4020 Assessment 3: Improvement Plan In-Service Presentation

References

• Abukhader, I., & Abukhader, K. (2020). Effect of medication safety education program on intensive care nurses’ knowledge regarding medication errors. Journal Of Biosciences And Medicines, 08(06), 135-147. https://doi.org/10.4236/jbm.2020.86013
• Hammoudi, B., Ismaile, S., & Abu Yahya, O. (2017). Factors associated with medication administration errors and why nurses fail to report them. Scandinavian Journal Of Caring Sciences, 32(3), 1038-1046. https://doi.org/10.1111/scs.12546
• Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?. BMJ Quality & Safety, bmjqs-2016-005991. https://doi.org/10.1136/bmjqs-2016-005991
• computerized physician order entry systems–related medication prescription errors: A systematic review. International Journal Of Medical Informatics, 111, 112-122. https://doi.org/10.1016/j.ijmedinf.2017.12.022
• Koyama, A., Maddox, C., Li, L., Bucknall, T., & Westbrook, J. (2021). Effectiveness of double checking to reduce medication administration errors: a systematic review. BJM Quality & Safety, 29(7). https://doi.org/http://dx.doi.org/10.1136/bmjqs-2019-009552
• Manias, E. (2018). Effects of interdisciplinary collaboration in hospitals on medication errors: an integrative review. Expert Opinion On Drug Safety, 17(3), 259-275. https://doi.org/10.1080/14740338.2018.1424830
• Risør, B., Lisby, M., & Sørensen, J. (2018). Complex automated medication systems reduce medication administration errors in a Danish acute medical unit. International Journal For Quality In Health Care, 30(6), 457-465. https://doi.org/10.1093/intqhc/mzy042
• Tariq, R., Vashisht, V., Sinha, A., & Scherbak, y. (2021). Medication dispensing errors and prevention. Retrieved 17 March 2021, from https://www.ncbi.nlm.nih.gov/books/NBK519065/.
• Thompson, K., Swanson, K., Cox, D., Kirchner, R., Russell, J., & Wermers, R. et al. (2018). Implementation of bar-code medication administration to reduce patient harm. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 2(4), 342-351. https://doi.org/10.1016/j.mayocpiqo.2018.09.001

NURS FPX 4020 Assessment 3: Improvement Plan In-Service Presentation.